Tiger Woods comeback after multiple back surgeries was derailed recently when he pulled out of the Omega Dubai Desert Classic, citing back spasms as the official reason. It’s been more than eighteen months since he underwent his last procedure. So why has he still not been able to return to his old form?

Athletes frequently undergo microscopic or endoscopic procedures in the shoulders or knees and are back on the field after only a few weeks or months. Lumbar microdiscectomy surgeries (the type that Tiger underwent) are also microscopic with an incision of only one inch or less and are considered outpatient procedures. It is not unusual for motivated patients with nonphysical jobs to return to at least part time work within one week of surgery.

Why It's Hard for Professional Athletes to Recover from "Minor" Back Surgery

So why do professional athletes have such a difficult time recovering from such a “minor” back surgery? The reason is that most sports demand a high degree of coordinated functionality from the core muscles that include the muscles surrounding the spine and the abdominal muscles. These muscles work in conjunction with the spinal column to support our bodies when we are turning, twisting, bending, and jumping during our sporting endeavors.

The spinal column consists of the vertebral bodies (aka back bone), discs, facets and five ligaments. The discs and the facets are the “joints” in the spine. Discs serve as the main joints and sit in front of the spinal sac. The facets are smaller and reside behind the spinal sac, one on each side. These joints are unlike any of the other simple joints in the arms and legs like the elbow (hinge) or hips (ball/socket). The discs bear most of the axial load and allow but resist range of motion in all directions. The primary role of the facets is to both resist and support twisting and bending. When a standard lumbar microdiscectomy surgery is performed, a small midline incision is made in the skin and a unilateral dissection of the paraspinal muscles on the side of the disc herniation is made. Then a small opening the size of a dime is made in the side of the spinal canal by drilling away bone. This necessitates taking a small part of the facet and the ligament on that side. By definition this takes away some of the mechanical spinal support that is needed as explained above.

Because normal function requires all of these many elements to work in sync, rehab following back surgery can be difficult and time consuming. The problem is exacerbated exponentially when a second surgery is required for a residual or reherniated disc. This is because, typically, more of the bone including the facet needs to be drilled off in order to expose the nerve and the disc fragment safely. The procedure can further destabilize the spinal column.

The Next Step for Tiger Woods

It’s difficult to predict where Tiger goes from here without knowing the medical details, but most patients in this situation end up needing a total disc replacement or a fusion. The problem is that the underlying disc that has ruptured or herniated is a worn out disc with a hole. The microdisc surgeries that Tiger had previously are designed to move the disc fragment away from the nerve to relieve pressure. But the hole in the disc annulus (belt of fibers surrounding disc) cannot be repaired surgically. Therefore, time needs to pass for the body to seal this up on its own with scar tissue. This process takes months and may not fully heal for up to one year. Even after healing completely, the disc remains weak, much like a worn out tire that had a hole patched. This is the reason that Peyton Manning ultimately had to have an anterior cervical discectomy and fusion.

A fusion procedure addresses the weak disc by removing it entirely and replacing with a bone or artificial spacer. Alternatively, a total disc replacement surgery can be performed in selected cases depending on the condition of the adjacent lumbar segments.

Hopefully Tiger will be able, through further rehab and conditioning, regain the strength, flexibility and range of motion needed to perform at his top level. But it will certainly not be easy.